Yoga for the Treatment of Insomnia Among Cancer Patients— Evidence, Mechanisms of Action, and Clinical Recommendations

Oncology & Hematology Review, 2014;10(2):164–8

Abstract:

Up to 90 % of cancer patients report symptoms of insomnia during and after treatment. Symptoms of insomnia include excessive daytime sleepiness, difficulty falling asleep, difficulty staying asleep, and waking up too early. Insomnia symptoms are among the most prevalent, distressing, and persistent cancer- and cancer treatment-related toxicities reported by patients and can be severe enough to increase cancer morbidity and mortality. Despite the ubiquity of insomnia symptoms, they are underscreened, underdiagnosed, and undertreated in cancer patients. When insomnia symptoms are identified, providers are hesitant to prescribe pharmaceuticals, and patients are reluctant to take them due to polypharmacy concerns. In addition, sleep medications do not cure insomnia. Yoga is a well-tolerated mode of exercise with promising evidence for its efficacy in improving insomnia symptoms among cancer patients. This article reviews existing clinical research on the effectiveness of yoga for treating insomnia among cancer patients. The article also provides clinical recommendations for prescribing yoga for the treatment of insomnia in this population.

Keywords: Yoga, sleep, insomnia, cancer, exercise
Disclosure: Karen M Mustian, PhD, MPH, Michelle Janelsins, PhD, MPH, Luke J Peppone, PhD, MPH, and Charles Kamen, PhD, MPH, have no conflicts of interest to declare.
Received: October 16, 2014 Accepted October 23, 2014 Citation Oncology & Hematology Review, 2014;10(2):164–8
Correspondence: Karen M Mustian, PhD, MPH, University of Rochester School of Medicine, Wilmot Cancer Institute, Department of Surgery, PEAK Lab, 265 Crittenden Boulevard, Rochester, NY 14642, US. E: Karen_Mustian@urmc.rochester.edu
Support: Funding was provided by NCI UG1 CA189961, R01 CA181064, K07 CA168886, K07 CA168911, and R25 CA102618.

Up to 90 % of cancer patients report symptoms of insomnia during and post-treatment, such as excessive daytime napping, difficulty falling asleep, difficulty staying asleep, and waking up too early.1–10 A diagnosis of insomnia is made when one or more of these symptoms (e.g. difficulty falling asleep or difficulty staying asleep) is present in a severe and persistent form (e.g. occurring for 3 or more days per week for 1 month or longer).11 Insomnia and its symptoms are among the most prevalent and distressing problems reported by cancer patients.1–10,12,13 They increase the risk for fatigue and depression, impair treatment adherence, diminish physiologic function, and worsen quality of life (QOL).1–10,12,13 When insomnia symptoms are severe and become chronic, they may increase morbidity and play an indirect part in affecting mortality.1–10,12,13 Despite the ubiquity of insomnia symptoms, they are underscreened, underdiagnosed, and undertreated in cancer patients.1–10,12,14

Treatment options for insomnia and its symptoms include exercise, pharmaceuticals, and psychobehavioral interventions.1–10,13 Unfortunately, pharmaceuticals do not cure insomnia and can lead to toxicities, negative interactions with cancer therapeutics (e.g. polypharmacy toxicities), dependency, and rebound impairment after discontinuing their use.1–10,13

Traditional exercise is recommended in insomnia treatment guidelines, but not widely implemented in survivorship care plans.1–10,13 In most circumstances, if oncology professionals do suggest exercise to their patients, they only provide general, nonspecific recommendations, encouraging patients to be more physically active, instead of delivering individualized exercise prescriptions. Psychobehavioral interventions, such as cognitive behavioral therapy for insomnia (CBT-I), are considered the gold standard in terms of efficacy, but they can be demanding in terms of time and effort. These difficulties can result in low adherence among patients undergoing active treatment.1–10,13 Yoga is a well-tolerated exercise intervention with promising scientific evidence demonstrating its efficacy for improving insomnia symptoms among cancer patients.

Yoga
Yoga is an increasingly popular mind–body practice that is also characterized as a mindfulness mode of physical exercise.15–18 There are many different styles and types of yoga. They are based on Eastern traditions from India (e.g. Classical, Advaita Vedanta, Tantra) and Tibet (e.g. Tibetan).15,19,20 The word ‘yoga’ is derived from its Sanskrit root, ‘yuj,’ which literally means ‘to yoke’ or join together. In this case, yoga refers to joining the mind and the body.15,19,20 The earliest forms of yoga were firmly rooted in physical and mindful (breathing and meditative) practices. These practices led to what is known as classical yoga, which forms the basis for most of the yoga currently taught today.19 Hatha yoga, the foundation of all yoga styles and the most popular form, includes both Gentle Hatha and Restorative yoga, and is growing in acceptance for therapeutic use in traditional Western medicine.13,15–18,21–24 Gentle Hatha yoga focuses on physical postures and is part of many styles of yoga, including Iyengar, Anusara, and others.15–18,21 Restorative yoga focuses on full relaxation and is part of the Iyengar style.25,26 The combination of Gentle Hatha and Restorative yoga may provide an effective approach for improving insomnia as it incorporates a holistic sequence of meditative, breathing, and physical alignment exercises, requiring both the active and passive engagement of skeletal muscles.15,16,21,22,25,26 Existing scientific evidence suggests that yoga is effective for improving insomnia symptoms in cancer patients.13,20,27–36

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Keywords: Yoga, sleep, insomnia, cancer, exercise